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Sinusitis
:See also: Sinusitis, also known as a sinus infection or rhinosinusitis, is of the that lines the resulting in symptoms. Common symptoms include thick , a , and . Other signs and symptoms may include , s, a , , and a . The cough is often worse at night. Serious complications are rare. It is defined as sinusitis if it lasts less than 4 weeks, and as sinusitis if it lasts for more than 12 weeks. Sinusitis can be caused by , , , or structural problems in the nose. Most cases are caused by a . A may be present if symptoms last more than 10 days or if a person worsens after starting to improve. Recurrent episodes are more likely in persons with , , and . are not usually needed unless complications are suspected. In chronic cases, confirmatory testing is recommended by either direct visualization or . Some cases may be prevented by hand washing, avoiding smoking, and . such as , s, and may be used to help with symptoms. Recommended initial treatment for acute sinusitis is . If symptoms do not improve in 7–10 days or get worse, then an may be used or changed. In those in whom antibiotics are used, either or is recommended first line. Surgery may occasionally be used in people with chronic disease. Sinusitis is a common condition. It affects between about 10 and 30 percent of people each year in the United States and Europe. Women are more often affected than men. Chronic sinusitis affects about 12.5% of people. Treatment of sinusitis in the United States results in more than 11 billion in costs. The unnecessary and ineffective treatment of viral sinusitis with antibiotics is common. Signs and symptoms Headache or facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is usually localized to the involved sinus and may worsen when the affected person bends over or when . Pain often starts on one side of the head and progresses to both sides. Acute sinusitis may be accompanied by thick that is usually green in color and may contain or blood. Often, a localized headache or is present, and these symptoms distinguish a sinus-related headache from other types of headaches, such as tension and headaches. Another way to distinguish between toothache and sinusitis is that the pain in sinusitis is usually worsened by tilting the head forwards and with s. Infection of the eye socket is possible, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is the infection of the bones ( ) of the forehead and other facial bones – . Sinus infections can also cause middle-ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, "a pressurized or heavy head", or vibrating sensations in the head. is also a symptom of chronic rhinosinusitis. (bad breath) is often stated to be a symptom of chronic rhinosinusitis; however, gold-standard breath analysis techniques have not been applied. Theoretically, several possible mechanisms of both objective and subjective halitosis may be involved. A 2004 study suggested that up to 90% of "sinus headaches" are actually migraines. The confusion occurs in part because migraine involves activation of the , which innervate both the sinus region and the surrounding the brain. As a result, accurately determining the site from which the pain originates is difficult. People with migraines do not typically have the thick nasal discharge that is a common symptom of a sinus infection. By location The four paired are the frontal, ethmoidal, maxillary, and sphenoidal sinuses. The es are further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the of the . In addition to the severity of , discussed below, sinusitis can be classified by the sinus cavity it affects: * – can cause or pressure in the maxillary ( ) area (e.g., toothache, or ) (J01.0/J32.0) * – can cause pain or pressure in the frontal sinus cavity (located above the eyes), headache, particularly in the forehead (J01.1/J32.1) * al – can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the ), and headaches (J01.2/J32.2) * al – can cause pain or pressure behind the eyes, but is often in the , over the es, or the back of the head. Complications The proximity of the brain to the sinuses makes the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of through the bones or s. , , and other life-threatening conditions may result. In extreme cases, the patient may experience mild personality changes, headache, altered consciousness, visual problems, seizures, , and possibly death. Sinus infection can spread through veins or by direct extension to close structures. Orbital complications were categorized by Chandler et al. into five stages according to their severity (see table). Contiguous spread to the orbit may result in periorbital , subperiosteal , orbital cellulitis, and abscess. Orbital cellulitis can complicate acute if anterior and posterior s enables the spread of the infection to the lateral or orbital side of the . Sinusitis may extend to the , where it may cause cavernous sinus , retrograde , and epidural, subdural, and brain abscesses. Orbital symptoms frequently precede intracranial spread of the infection . Other complications include sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis. of the frontal bone often originates from a spreading . A of the frontal sinus causes an and a of the outer membrane, which produces a tender, puffy swelling of the forehead. The diagnosis of these complications can be assisted by noting local tenderness and dull pain, and can be confirmed by and nuclear scanning. The most common causes are and . Treatment includes performing surgical drainage and administration of antimicrobial therapy. Surgical is rarely required after an extended course of antimicrobial therapy. Antibiotics should be administered for at least 6 weeks. Continuous monitoring of people for possible intracranial complication is advised. Causes sinusitis may also develop from problems with the teeth, and these cases make up between 10 and 40% of cases. The cause of this situation is usually a or infection of a maxillary tooth, where the inflammatory has eroded through the bone superiorly to drain into the maxillary sinus. Once an involves the maxillary sinus, it may then spread to the or to the , the nasal cavity, and frontal sinuses, and in unusual instances can spread from the maxillary sinus causing orbital , blindness, , subdural , and life-threatening cavernous sinus . Limited field imaging, as compared to s, improves the ability to detect the teeth as the sources for sinusitis. Treatment focuses on removing the infection and preventing reinfection, by removing of the s, their byproducts, and pulpal debris from the infected . Systemic s is ineffective as a definitive solution, but may afford temporary relief of symptoms by improving sinus clearing, and may be appropriate for rapidly spreading infections, but and disinfection of the root canal system at the same time is necessary. Chronic sinusitis can also be caused indirectly through a common but slight abnormality in the auditory or , which is connected to the sinus cavities and the throat. Other diseases such as and can also cause chronic sinusitis. This tube is usually almost level with the s, but when this sometimes hereditary abnormality is present, it is below this level and sometimes level with the vestibule or nasal entrance. Acute sinusitis is usually precipitated by an earlier , generally of origin, mostly caused by es, es, and , others caused by , , , es other than rhinoviruses, and . If the infection is of bacterial origin, the most common three causative agents are , , and . Until recently, H. influenzae was the most common bacterial agent to cause sinus infections. However, introduction of the H. influenzae type B (Hib) vaccine has dramatically decreased these infections and now non-typable H. influenzae (NTHI) is predominantly seen in clinics. Other sinusitis-causing s include S. aureus}} and other , and, less commonly, bacteria. Viral sinusitis typically lasts for 7 to 10 days, whereas bacterial sinusitis is more persistent. Around 0.5 to 2.0% of viral sinusitis results in subsequent bacterial sinusitis. Nhat nasal irritation from is thought to lead to the secondary bacterial infection. episodes of sinusitis can also result from invasion. These infections are typically seen in people with or other (such as or on immunosuppressive antirejection medications) and can be life-threatening. In type I diabetics, ketoacidosis can be associated with sinusitis due to . Chemical irritation can also trigger sinusitis, commonly from cigarette smoke and fumes. It may also be caused by a tooth infection. Chronic By definition, chronic sinusitis lasts longer than 12 weeks and can be caused by many different diseases that share chronic inflammation of the sinuses as a common symptom. Symptoms may include any combination of: , facial pain, , night-time coughing, an increase in previously minor or controlled asthma symptoms, general , thick green or yellow , feeling of facial fullness or tightness that may worsen when bending over, dizziness, aching teeth, and/or . Each of these symptoms has multiple other possible causes, which should be considered and investigated, as well. Often, chronic sinusitis can lead to , the inability to objects. In a small number of cases, acute or chronic itis is associated with a dental infection. , , and are not typical in chronic sinusitis and other causes should be investigated. Chronic sinusitis cases are subdivided into cases with and without . When polyps are present, the condition is called chronic sinusitis; however, the causes are poorly understood and may include allergy, environmental factors such as dust or pollution, bacterial infection, or fungi (either allergic, infective, or reactive). Chronic rhinosinusitis represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection. The medical management of chronic rhinosinusitis is now focused upon controlling the inflammation that predisposes people to obstruction, reducing the incidence of infections. However, all forms of chronic rhinosinusitis are associated with impaired sinus drainage and secondary bacterial infections. Most individuals require initial antibiotics to clear any infection and intermittently afterwards to treat acute exacerbations of chronic rhinosinusitis. A combination of is detected in conjunction with chronic sinusitis. Also isolated are S. aureus, including , and -negative staphylococci and Gram-negative enteric bacteria can be isolated. Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. The presence of in the mucous lining of the nose and paranasal sinuses has been demonstrated for many people, and this has been termed eosinophilic mucin rhinosinusitis (EMRS). Cases of EMRS may be related to an allergic response, but allergy is not often documented, resulting in further subcategorization into allergic and nonallergic EMRS. A more recent, and still debated, development in chronic sinusitis is the role that play in this disease. Whether fungi are a definite factor in the development of chronic sinusitis remains unclear, and if they are, what is the difference between those who develop the disease and those who remain free of symptoms. Trials of antifungal treatments have had mixed results. Recent theories of sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the (i.e., the "one airway" theory) and is often linked to . All forms of sinusitis may either result in, or be a part of, a generalized inflammation of the airway, so other airway symptoms, such as cough, may be associated with it. Both smoking and are associated with chronic rhinosinusitis. Pathophysiology bacterial s may account for many cases of -refractory chronic sinusitis. Biofilms are complex aggregates of and interdependent s from multiple species, many of which may be difficult or impossible to using standard techniques. Bacteria found in biofilms have their increased up to 1000 times when compared to free-living bacteria of the same species. A recent study found that biofilms were present on the of 75% of people undergoing surgery for chronic sinusitis. Diagnosis Classification Sinusitis (or rhinosinusitis) is defined as an inflammation of the that lines the and is classified chronologically into several categories: * sinusitis – A new infection that may last up to four weeks and can be subdivided symptomatically into severe and nonsevere. Some use definitions up to 12 weeks. * Recurrent acute sinusitis – Four or more full episodes of acute sinusitis that occur within one year * sinusitis – An infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection * sinusitis – When the signs and symptoms last for more than 12 weeks. * Acute exacerbation of chronic sinusitis – When the signs and symptoms of chronic sinusitis exacerbate, but return to baseline after treatment Roughly 90% of adults have had sinusitis at some point in their lives. Acute Health care providers distinguish bacterial and viral sinusitis by . If a person has had sinusitis for fewer than 10 days without the symptoms becoming worse, then the infection is presumed to be viral. When symptoms last more than 10 days or get worse in that time, then the infection is considered bacterial sinusitis. Pain in the teeth and bad breath are also more indicative of bacterial disease. Imaging by either X-ray, CT or MRI is generally not recommended unless complications develop. Pain caused by sinusitis is sometimes confused for pain caused by (toothache) of the maxillary teeth, and vice versa. Classically, the increased pain when tilting the head forwards separates sinusitis from pulpitis. Chronic For sinusitis lasting more than 12 weeks, a CT scan is recommended. On a CT scan, acute sinus secretions have a of 10 to 25 s (HU), but in a more chronic state they become more , with a radiodensity of 30 to 60 HU. Nasal and clinical symptoms are also used to make a positive diagnosis. A tissue sample for and can also be collected and tested. Allergic sinusitis (AFS) is often seen in people with and s. In rare cases, may be made. Nasal endoscopy involves inserting a flexible tube with a light and camera at its tip into the nose to examine the nasal passages and sinuses. This is generally a completely painless (although uncomfortable) procedure that takes 5-10 minutes to complete. Image:Sinuses and Sinusitis (5937085231).jpg|CT of chronic sinusitis File:CT of chronic sinuitis.jpg| of chronic sinusitis, showing a filled right maxillary sinus with sclerotic thickened bone. File:Brain MRI 112010 rgbca.png|MRI image showing sinusitis. Edema and mucosal thickening appears in both maxillary sinuses. File:RtmaxobitinfectteethCT.png|Maxillary sinusitis caused by a dental infection associated with File:FrontalSinusitisMark.png|Frontal sinusitis File:Maxilar sinusites.jpg| of left-sided maxillary sinusitis marked by an arrow. There is lack of the air transparency indicating fluid in contrast to the other side. Treatment Recommended treatments for most cases of sinusitis include rest and drinking enough water to thin the mucus. Antibiotics are not recommended for most cases. Breathing low-temperature steam such as from a hot shower or can relieve symptoms. There is tentative evidence for in acute sinusitis, for example during s. s containing may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause . It is unclear if nasal irrigation, s, or decongestants work in children with acute sinusitis. Antibiotics Most sinusitis cases are caused by viruses and resolve without antibiotics. However, if symptoms do not resolve within 10 days, is a reasonable antibiotic for , with being indicated if symptoms do not improve after 7 days on amoxicillin alone. A 2012 Cochrane review, however, found only a small benefit between 7 and 14 days, and could not recommend the practice when compared to potential complications and risk of developing resistance. Antibiotics are specifically not recommended in those with mild / moderate disease during the first week of infection due to risk of adverse effects, , and cost. , and a newer antibiotic such as or a like , are used in those who have severe allergies to s. Because of increasing resistance to amoxicillin the 2012 guideline of the recommends amoxicillin-clavulanate as the initial treatment of choice for bacterial sinusitis. The guidelines also recommend against other commonly used antibiotics, including , , and , because of growing antibiotic resistance. The recommends against the use of s when other options are available due to higher risks of serious s. A short-course (3–7 days) of antibiotics seems to be just as effective as the typical longer-course (10–14 days) of antibiotics for those with clinically diagnosed acute bacterial sinusitis without any other severe disease or complicating factors. The guideline suggest five to seven days of antibiotics is long enough to treat a bacterial infection without encouraging resistance. The guidelines still recommend children receive antibiotic treatment for ten days to two weeks. Corticosteroids For unconfirmed acute sinusitis, using s have not been found to be better than a either alone or in combination with antibiotics. For cases confirmed by radiology or nasal endoscopy, treatment with intranasal corticosteroids alone or in combination with antibiotics is supported. The benefit, however, is small. There is only limited evidence to support short treatment with oral corticosteroids for chronic rhinosinusitis with nasal polyps. There is limited evidence to support oral corticosteroids in combination with antibiotics for acute sinusitis; it has only short-term effect improving the symptoms. Surgery For chronic or recurring sinusitis, referral to an may be indicated, and treatment options may include nasal surgery. Surgery should only be considered for those people who do not benefit with medication. It is unclear how benefits of surgery compare to medical treatments in those with nasal polyps as this has been poorly studied. involves puncturing the sinus and flushing with to clear the mucus. A 1996 study of people with chronic sinusitis found that washout confers no additional benefits over antibiotics alone. A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal ones. The benefit of (FESS) is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications. The use of such as may help in recovery after surgery. Another recently developed treatment is . This method, similar to used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. For persistent symptoms and disease in people who have failed medical and the functional endoscopic approaches, older techniques can be used to address the inflammation of the maxillary sinus, such as the . This surgery involves an incision in the upper gum, opening in the anterior wall of the , removal of the entire diseased maxillary sinus mucosa and drainage is allowed into or by creating a large window in the lateral nasal wall. Epidemiology Sinusitis is a common condition, with between 24 and 31 million cases occurring in the United States annually. Chronic sinusitis affects approximately 12.5% of people. Research Based on recent theories on the role that may play in the development of chronic sinusitis, antifungal treatments have been used, on a trial basis. These trials have had mixed results. References Category:Medical